ACP: New Recommendations Regarding Blood Glucose Control

Intensive insulin therapy leads to increased risk of hypoglycemia in ICU patients without any added benefit….

Hyperglycemia is a common complication associated with poor outcomes in intensive care unit patients. In the past, intensive insulin therapy has been used to achieve blood glucose levels <140mg/dL. However recent evidence shows no difference in morbidity but increased hypoglycemia between strict control of blood glucose compared to less intensive control.

Published in American Journal of Medical Quality, the American College of Physicians (ACP) Clinical Guidelines Committee suggests that the development of hypoglycemia due to intensive insulin therapy can lead to risk for dementia, transient ischemia, and catecholamine surges as well as increased medical cost due to increased nursing staff hours.

Amir Qaseem, MD, PhD, MHA, FACP, Director, Clinical Policy, ACP added, "The current evidence does not support that the benefits of intensive insulin therapy outweigh its harms. In addition, intensive insulin therapy consumes more resources and is more expensive than managing hyperglycemia with standard therapy."

ACP recommends that the target blood glucose level of 140 to 200 mg/dL should be used in surgical or medical intensive care unit patients (SICU/MICU). ACP reported no difference in mortality for insulin therapy targeted at blood glucose levels of 140-200 mg/dL compared to strict glucose control with levels 80-110 mg/dL. ACP noted that the use of intensive insulin therapy was associated with six times the risk of developing hypoglycemia compared to standard therapy.

Qaseem concluded, "Clinicians caring for hospitalized patients must keep the harms of hypoglycemia in mind when managing hyperglycemia and should avoid aggressive glucose management. Intensive insulin therapy should not be used to strictly control blood glucose or to normalize blood glucose in SICU and MICU patients with or without diabetes."

ACP Best Practice Advice

Clinicians should target a blood glucose level of 7.8 to 11.1 mmol/L (140-200 mg/dL) if insulin therapy is used in SICU/MICU patients.

Clinicians should avoid targets less than 7.8 mmol/L (<140 mg/dL) because harms are likely to increase with lower blood glucose targets.

Amir Qaseem, Roger Chou, Linda L. Humphrey, Paul Shekelle, for the Clinical Guidelines Committee of the American College of Physicians. Inpatient Glycemic Control: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. American Journal of Medical Quality, 2013; DOI: 10.1177/1062860613489339